When Kaiser Permanente members are transitioning home after a hospital stay, our goal at CMI is to help ensure a safe, reliable and quality return home. CMI’s ‘Transitions of Care’ initiative includes the exploration of different models of care to improve transitions, including follow-up calls, pharmacist medication reconciliation, and timely information exchange with outside organizations. All models address the following five key components of a safe transition:
- Assessment of member and caregiver needs
- Plan of care
- Medication management
- Timely exchange of health information
- Proactive follow-up care